This year, I have been focusing on chiropractic scope of practice because the state scope laws define our profession and determine our future within health care systems throughout the U.S. In this article, I question the rationale for a narrow scope of practice for chiropractors and address the need to modernize antiquated practice acts, starting with acts that require detection and correction of nerve interference.
The New York Example
Currently, the New York chiropractic practice act limits chiropractic care with its requirement to detect and correct conditions in order to remove nerve interference. All chiropractors in New York should be concerned with this restriction, which could be attacked by the American Medical Association as unscientific. It is my opinion that this definition (§6551. Definition of practice of chiropractic) is neither reasonable nor evidence-based:
1. The practice of the profession of chiropractic is defined as detecting and correcting by manual or mechanical means structural imbalance, distortion, or subluxations in the human body for the purpose of removing nerve interference and the effects thereof, where such interference is the result of or related to distortion, misalignment or subluxation of or in the vertebral column.
2. (a) A license to practice as a chiropractor shall not permit the holder thereof to use radio-therapy, fluoroscopy, or any form of ionizing radiation except X-ray which shall be used for the detection of structural imbalance, distortion, or subluxations in the human body.1
I have been a chiropractic clinician since 1972. I am licensed to practice as a chiropractic physician in New Mexico and Connecticut. My postgraduate training includes chiropractic orthopedics and board certification as a chiropractic orthopedist. I have taught postgraduate chiropractic education for chiropractic colleges and served as a preceptor and postceptor for medical schools including allopathic and chiropractic institutions. Yet I do not claim to be able to detect nerve interference with every patient who presents with spinal joint dysfunctions in need of a spinal manipulation. If I were licensed to practice in New York, would I not be breaking the law if I treated patients without detecting and correcting nerve interference?
Challenging Antiquity With Logic
How would I prove that I am detecting nerve interference and removing it with chiropractic care? Well, if a patient presents with spinal nerve root compression and subsequent radiculopathy or peripheral neuropathies, I could perform a neurological examination and demonstrate sensory and/or motor deficits, which would indicate nerve interference. Subsequent neurological examinations could reveal resolution of the neurological deficits, which would demonstrate correction of nerve interference. In fact, neurodiagnostics might confirm the nerve interference.
Yet I pose this question: Do chiropractors in New York perform spinal manipulation to relieve patients suffering with conditions such as neck pain, cervicogenic headaches or low back pain and demonstrate scientific, evidence-based proof of removing nerve interference? The answer to this rhetorical question is, of course, that they do! Although I am not an attorney, according to the New York law and the definition of chiropractic practice, it appears to be illegal for a chiropractor to treat a patient without demonstrating nerve interference.
The next logical question for your consideration: Does science support detection and correction of nerve interference, which are the requirements necessary to practice chiropractic in New York? A Pubmed search using the phrase nerve interference and chiropractic revealed only one article that addressed the chiropractic requirement to detect and correct nerve interference:
Chiropractic health care is founded on the premise that many diseases are the result of spinal nerve impingements or interference. These nerve impingements are postulated to be the result of misaligned vertebra or "subluxations." Research indicates that spinal manipulation may be beneficial in low back pain, but the claim that spinal manipulation is of value for optimizing general health and treating non-musculoskeletal conditions is unfounded.2
The Flip Side of the Coin
A Pubmed search of chiropractic and chronic pain revealed more than 500 articles. One of these studies described the methodology for a randomized, controlled trial evaluating the dose-response of spinal manipulation for chronic cervicogenic headache in an adult population.
The abstract described this pilot study as a mixed-methods, two-site, prospective, parallel-groups, observer-blind, randomized, controlled trial that will be conducted at university-affiliated research clinics in the Portland, Ore., and Minneapolis, Minn., areas. The primary outcome will be patient-reported headache frequency.
This will be the first full-scale randomized, controlled trial assessing the dose-response of spinal manipulation therapy on outcomes for cervicogenic headache. The results of this study will provide important evidence for the management of cervicogenic headache in adults.3
This study is concerned with intensity of pain, quality of life, disability, patient improvement, neck pain frequency, medication use, and patient satisfaction. Cervical spine dysfunction (cervical joint tenderness and/or restricted segmental motion) was required to be demonstrated, but there was no need to determine the presence of nerve interference or the correction of it with chiropractic care.
I doubt any scientific articles require the detection and correction of nerve interference in order to justify the use of spinal manipulation for the treatment of patients with painful, neuromusculoskeletal conditions. If the chiropractic profession is to offer evidence-based, patient-centered care to patients in need of medical services, the chiropractic practice acts must be changed through legislative efforts. Is it not unethical for members of chiropractic state boards of examiners to require chiropractors to provide services that cannot be supported by science?
In short, it is time to modernize chiropractic practice acts: eliminate the requirement to detect and correct nerve interference.
References
Editor's Note: Visit Dr. Lehman's online columnist page to read his previous discussions of chiropractic scope, including use of the term primary spine care practitioner; the fact that the definition of chiropractic varies from state to state; the loss of privileges to diagnose in Texas (which have since been regained; see the front page of this issue); and the need for evidence-based, patient-centered care.
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